DISSERTATION SUBMITTED IN FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF DETAL SCIENCE

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(1)al a. ya. COMPARISON OF ORAL HEALTH AND NUTRITIONAL STATUS BETWEEN HOSPITALISED AND NONHOSPITALISED ELDERLY IN A SELECTED URBAN MALAYSIAN POPULATION. ve. rs. ity. of. M. VAISHALI MALHOTRA. U. ni. DEPARTMENT OF RESTORATIVE DENTISTRY, FACULTY OF DENTISTRY UNIVERSITY OF MALAYA KUALA LUMPUR. 2019.

(2) al a. ya. COMPARISON OF ORAL HEALTH AND NUTRITIONAL STATUS BETWEEN HOSPITALISED AND NON-HOSPITALISED ELDERLY IN A SELECTED URBAN MALAYSIAN POPULATION. of. M. VAISHALI MALHOTRA. rs. ity. DISSERTATION SUBMITTED IN FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF DETAL SCIENCE. UNIVERSITY OF MALAYA KUALA LUMPUR. U. ni. ve. DEPARTMENT OF RESTORATIVE DENTISTRY, FACULTY OF DENTISTRY. 2019.

(3) UNIVERSITY OF MALAYA ORIGINAL LITERARY WORK DECLARATION Name of Candidate: Vaishali Malhotra Matric No: DGC140006 Name of Degree: Master of Dental Science.. al a. ya. Title of Dissertation/Thesis (“this Work”): Comparison of oral health and nutritional status between hospitalised and non-hospitalised elderly in a selected urban Malaysian population. Field of Study: Special Needs Dentistry, Geriatric Dentistry, Community Dentistry. M. I do solemnly and sincerely declare that:. U. ni. ve. rs. ity. of. (1) I am the sole author/writer of this Work; (2) This Work is original; (3) Any use of any work in which copyright exists was done by way of fair dealing and for permitted purposes and any excerpt or extract from, or reference to or reproduction of any copyright work has been disclosed expressly and sufficiently and the title of the Work and its authorship have been acknowledged in this Work; (4) I do not have any actual knowledge nor do I ought reasonably to know that the making of this work constitutes an infringement of any copyright work; (5) I hereby assign all and every rights in the copyright to this Work to the University of Malaya (“UM”), who henceforth shall be owner of the copyright in this Work and that any reproduction or use in any form or by any means whatsoever is prohibited without the written consent of UM having been first had and obtained; (6) I am fully aware that if in the course of making this Work I have infringed any copyright whether intentionally or otherwise, I may be subject to legal action or any other action as may be determined by UM. Candidate’s Signature. Date:. Subscribed and solemnly declared before, Witness’s Signature. Date:. Name: Designation:. ii.

(4) ABSTRACT. Introduction Malaysia is rapidly advancing towards the status of an ageing nation. Demographic transitions pose major challenges for health care providers in planning and providing effective and holistic health care to institutionalized older people. Health authorities are. ya. experiencing an increasing public health problem; the growing burden of oral diseases among older people. The concept of oral health has evolved from just having healthy. al a. teeth. Holistic oral health includes excellent oral function which is the ability to smile, speak, swallow and chew competently, and without pain; bringing about improvement. M. in general health and increased self-esteem. However, in the present scenario, the oral health of older Malaysians is far from optimal.. of. Aim. ity. The purpose of this study was to compare the oral health and nutritional status between the hospitalised and non-hospitalised urban elderly population.. rs. Materials and Methods. ve. An observational, comparative cross-sectional study was conducted. Cases were a convenience sample was obtained from the geriatric wards at the University of Malaya. ni. Medical Centre while matched controls were selected from the Malaysian Elders. U. Longitudinal Research (MELoR) study. A structured questionnaire was administered face-to-face to obtain socio-demographics, medical history, oral health related knowledge, attitude and practices, and nutrition status. Clinical assessments including dentition status, salivation status and periodontal health status were conducted by trained, calibrated dentists.. iii.

(5) Results 148 (74 hospitalised and 74 non-hospitalised) participants, mean age = 80.76 (±7.4) years, 54.1% women, age and gender matched, were recruited. The mean number of missing teeth was 23.12 (±10.1) in the hospitalised group and 17.34 (±5.5) in the nonhospitalised group (p < .001). Significantly fewer hospitalised individuals felt it was important to brush daily (p=0.003), visited the dentist in the last 2 years (p<0.001) and. ya. brushed their teeth more than once a day (p<0.001). Hospitalised individuals also had fewer sound teeth (p<0.001), fewer filled teeth (p<0.001) and more missing teeth. al a. (p<0.001). 67.7% of hospitalized participants and 17.6% of non-hospitalized controls were edentulous. All hospitalised participants who had teeth had chronic periodontal. M. disease compared to 80.2% of non-hospitalised controls (p<0.001). Hospitalised participants were significantly more likely to have moderately dry mouths than non-. of. hospitalised controls (p<0.001).. ity. Conclusions. The findings of this study reflect that oral health status in both groups was poor but. rs. overall it was significantly worse amongst those who were hospitalised. Hospitalised. ve. individuals also demonstrated poor knowledge, and more adverse attitudes and practices than non-hospitalised participants on dental care. Our study highlights an association. ni. between poor oral health and hospitalisation as a case-control study. Larger prospective. U. study should be conducted to confirm this relationship.. iv.

(6) ABSTRAK. Pengenalan. Malaysia dengan perlahan akan terus maju ke arah menjadi negara tertua. Peralihan demografik ini memberi cabaran besar kepada badan penjagaan kesihatan terutama nya bagi golongan warga emas. Lebih-lebih lagi, pihak berkuasa kesihatan tidak lama lagi. ya. akan menghadapi masalah kesihatan awam yang semakin meningkat antaranya bebanan. al a. terhadap penyakit mulut di kalangan warga emas. Konsep kesihatan mulut telah berubah dari hanya mempunyai gigi yang sihat termasuk lah fungsi lisan yang sangat baik. M. (keupayaan untuk bercakap, senyum, mengunyah dan menelan dengan cekap, dan tanpa rasa sakit), memperbaiki kesihatan awam dan meningkatkan jati diri. Walau. ity. baik dari paras optima.. of. bagaimanapun, pada masa kini, kesihatan mulut warga emas rakyat Malaysia jauh lebih. rs. Matlamat. ve. Tujuan kajian ini adalah untuk membandingkan masyarakat yang menerima rawatan dan tidak menerima rawatan bagi warga emas rakyat Malaysia dari segi kesihatan mulut. ni. dan kesihatan umum; ilmu pengetahuan, sikap dan amalan ke arah kesihatan mulut dan. U. status nutrisi serta faktor-faktor risiko yang mempengaruhi status pergigian.. Bahan dan Kaedah. Kajian rentas, pemerhatian, kawalan kes penyelidikan telah dijalankan. Kes kemasukan hospital dipilik secara convenience daripada wad-wad geriatrik di Pusat Perubatan Universiti Malaya. Peserta-peserta kawalan (kontrol) pula dipilih secara perpadanan dari Projek Kajian Penyelidikan Jangka Panjang Warga Emas Malaysia (MELoR. Soal selidik berstruktur digunakan untuk temuduga secara bersemuka untuk v.

(7) mendapatkan maklumat sosio-demografi, sejarah perubatan, pengetahuan berkaitan kesihatan mulut, sikap dan amalan; dan status nutrisi. Penilaian klinikal dijalankan oleh doktor gigi yang dilatih dan dikalibrasi untuk menilai status pergigian, status pengeluaran air liur dan status kesihatan periodontal.. Keputusan. ya. 148 (74 menerima rawatan dan 74 tidak menerima rawatan) peserta julat umur = 80.76 (± 7.4) tahun, 45.9% lelaki dan 54.1% wanita, umur dan jantina yang dipadankan,. al a. telah menerima pemeriksaan saringan kesihatan mulut. Purata bilangan gigi yang hilang ialah 23.12 (± 10.1) dalam kumpulan yang dirawat di hospital dan 17.34 (± 5.5) dalam. M. kumpulan tidak menerima rawatan hospital (p <.001). Individu dari hospital kurang kemungkinannya menyedari kepentingan menggosok setiap hari (p=0.003), melawat. of. doktor gigi dalam masa dua tahun yang terdekat (p<0.001) dan menggosok gigi lebih. ity. daripada satu kali sehari (p<0.001). Individi yang masuk hospital juga kekurangan gigi yang sempurna (p<0.001), gigi yang dirawat (p<0.001) dan lebih gigi yang hilang. rs. (p<0.001). 67.7% peserta dari hospital dan 17.6% peserta kawalan dari luar hospital. ve. tiada gigi. Semua peserta hospital yang berkepunyaan gigi ada penyakit gusi kronik berbanding dengan 80.2% peserta kawalan luar hospital (p<0.001). Peserta hospital juga. ni. lebih mengalami masalah mulut kering yang sederhana berbanding dengan peserta. U. kawalan yang tidak masuk hospital (p<0.001).. Kesimpulan. Penemuan menunjukkan bahawa kesihatan mulut dalam kedua-dua kumpulan adalah rendah dan keadaan menjadi lebih buruk di kalangan mereka yang menerima rawatan. Kajian ini juga mempamerkan kekurangan pengetahuan, dan sikap yang buruk berutamanya mereka yang masuk hospital, terhadap kesihatan gigi. Jadi, kesihatan. vi.

(8) mulut yang buruk mungkan berkena mengena dengan kemasukan hospital di golongan warga emas. Analisasi multivariate untuk menyelaraskan faktor-faktor yang mungkin menganggu perhubungan diantara kesihatan mulut dan gigi dengan kemasukan hospital perlu dijalankan. Kajian selanjutnya, yang harus dijalankan secara prospektif juga. U. ni. ve. rs. ity. of. M. al a. ya. diperlukan untuk menentukan perhubungan ini.. vii.

(9) ACKNOWLEDGEMENTS. The completion of my dissertation has only been possible due to the unstinted support I have received from my supervisors, fellow researchers, family and friends.. I would like to express my sincerest gratitude to each one of the contributors for their comments, criticism, questions, and encouragement both personal and professional. ya. which have enabled me to complete the dissertation.. al a. My deepest gratitude is to my supervisor Associate Professor Dr. Jacob John A/l Chiremel Chandy who supervised me through the Masters research. I have been. M. extremely favored to have a supervisor who gave me the freedom to explore on my own and at the same time the guidance to recover when my steps faltered. His patience and. of. support helped me overcome many critical situations and finish this dissertation. I will forever be grateful to him for guiding me, motivating me, being patient with me through. ity. the length of the project. I am also thankful to him for carefully reading and giving his. rs. expert advice on the countless revisions of this manuscript. I look forward to working. ve. under him on my next and many more.. My co-supervisor, Professor Dr. Tan Maw Pin has been always there to listen and. ni. give advice. I am deeply grateful to her for the long discussions as a mentor that helped. U. me sort out the technical details of my work. She inspires me to work harder, her encouragement gives me the confidence to perform better and her appreciation makes every bit worth it. I look up to Professor not only as my guide but personally too and hopefully can imbibe some bits of her work ethics.. Dr. Muhammad Abbas Amanat, his comments and constructive criticisms at different stage of my research were thought-provoking and they helped me focus my ideas. I am grateful to him for guiding me on very critical issues. viii.

(10) I am also indented to the members of the MELoR Team. I would like to acknowledge their continuous support for many valuable discussions that helped me understand my research area and team work better.. I am thankful to my friend Dr. Syed Amjad Abbas, who helped me through the hurdles during the implementation of the project and to many other friends especially Dr. Tharini Gunawardena, who have helped me stay steadfast through these difficult. ya. years. Their support and care helped me overcome setbacks and stay focused on my. al a. study. I greatly value their friendship and deeply appreciate their belief in me.. Most importantly none of this would have been possible without the love and. M. patience of my parents, my ever so supportive husband and my bundle of joy to all of whom this dissertation is dedicated to, they have been a constant source of love,. ity. gratitude to my family.. of. concern, support and strength all these years. I would like to express my heart-felt. rs. In advertently I may have missed some names, I hope that all those will forgive me. ve. and will still accept my sincere thanks for their influence on my work.. Finally, I appreciate the financial support from the two grants namely, University of. ni. Malaya High Impact Research (Grant number UM.C/625/HIR/MOHE/DENT/07) and. U. University. of. Malaya. High. Impact. Research. (Grant. number. UMC/625/HIR/MOHE/ASH02) that funded parts of the research discussed in this dissertation.. ix.

(11) TABLE OF CONTENTS. ABSTRACT .................................................................................................................. III ABSTRAK ...................................................................................................................... V ACKNOWLEDGEMENTS ...................................................................................... VIII TABLE OF CONTENTS............................................................................................... X LIST OF FIGURES ...................................................................................................XIV. ya. LIST OF TABLES ...................................................................................................... XV LIST OF SYMBOLS AND ABBREVIATIONS .....................................................XVI. al a. CHAPTER 1: INTRODUCTION .................................................................................. 1 Background .............................................................................................................. 1. 1.2. Aim of the Study...................................................................................................... 4. 1.3. Research Objectives ................................................................................................ 4. 1.4. Research Significance.............................................................................................. 4. 1.5. Null Hypothesis ....................................................................................................... 5. 1.6. Field of Research ..................................................................................................... 6. rs. ity. of. M. 1.1. ve. LITERATURE REVIEW ...................................................................... 7. Ageism and Ageing: Framework ............................................................................. 7. ni. 2.1. Age- categorization of the Elderly Population ........................................................ 8. U. 2.2 2.3. Population Ageing ................................................................................................... 9. 2.4. Ageing Index ......................................................................................................... 11. 2.5. The Impact of Aging on Oral and General Health ................................................ 11 2.5.1 Aging and General Health..................................................................... 11 2.5.2 Oral Health and General Health ............................................................ 12 2.5.3 Pulmonary Diseases .............................................................................. 12 2.5.3.1. Atherosclerotic Diseases (Coronary Heart Diseases and Cerebrovascular Diseases) .................................................. 13. x.

(12) 2.5.3.2. Diabetes Mellitus ................................................................ 14. 2.5.3.3. Osteoporosis ....................................................................... 15. 2.5.3.4. Chronic Kidney Diseases .................................................... 15. 2.5.3.5. Nutritional Status ................................................................ 15. 2.5.3.6. Xerostomia (Dry Mouth) .................................................... 18. 2.5.4 Ageing and Oral Health ........................................................................ 19 2.5.5 Age Related Dental Changes ................................................................ 20 Teeth ................................................................................... 20. 2.5.5.2. Oral Mucous Membrane ..................................................... 22. 2.5.5.3. Periodontitis ........................................................................ 22. 2.5.5.4. Changes in the Salivary Gland and Secretion..................... 24. ya. 2.5.5.1. al a. 2.5.6 The Incidence of Oral Diseases and Conditions ................................... 25 Caries .................................................................................. 25. 2.5.6.2. Tooth Loss and Edentulism ................................................ 27. 2.5.6.3. Periodontal Diseases ........................................................... 28. 2.5.6.4. Oral Mucosal Lesions and Oral Cancer .............................. 29. 2.5.6.5. Prosthetic Considerations ................................................... 30. of. M. 2.5.6.1. METHODOLOGY ............................................................................... 31 Study Design.......................................................................................................... 31. 3.2. Sample and Sampling Method ............................................................................... 31. rs. ity. 3.1. 3.2.1 Hospitalised Participants ....................................................................... 31. ve. 3.2.2 Non- Hospitalised Participants.............................................................. 32. Sample Size ........................................................................................................... 33. ni. 3.3. Inclusion and Exclusion Criteria ........................................................................... 34. U. 3.4 3.5. Ethical Consideration ............................................................................................ 35. 3.6. Measurements ........................................................................................................ 35 3.6.1 Interview Based Assessments ............................................................... 36 3.6.2 Clinical Assessment .............................................................................. 38 3.6.3 Oral Health Status (Dentition Status, Periodontal Heath Status and Levels of Dryness) ............................................................................ 38 3.6.3.1. Dentition Status .................................................................. 38. 3.6.3.2. Periodontal Health Status ................................................... 39. xi.

(13) 3.6.3.3. Level of Dryness of the Oral Cavity ................................... 40. 3.7. Standardization and Calibration ............................................................................ 42. 3.8. Data Collection ...................................................................................................... 43. 3.9. Data Management and Analysis ............................................................................ 44 RESULTS.............................................................................................. 46. 4.1. Results of Interview Based Assessments............................................................... 46. ya. 4.1.1 Demographic Profile and General Health Status .................................. 46. al a. 4.1.2 Comparison of the Oral Health Related Knowledge, Attitude and Practices between the Hospitalised and the Non-Hospitalised Groups ............................................................................................... 48. 4.2. M. 4.1.3 Nutritional Status Assessment between the Hospitalised and the NonHospitalised Groups .......................................................................... 50 Results for Clinical Assessments ........................................................................... 50. Dentition Status .................................................................. 50. ity. 4.2.1.1. of. 4.2.1 Comparison of the Dentition Status, Periodontal Health Status and Salivation Status between the Hospitalised and Non-Hospitalised Group ................................................................................................ 50 Periodontal Status ............................................................... 51. 4.2.1.3. Level of Dryness of the Oral Cavity ................................... 52. rs. 4.2.1.2. Factors Associated with Denture Wearing Status .............. 52. ve. 4.2.1.4. 4.3. Multivariate predictor models ............................................................................... 53. ni. DISCUSSION ....................................................................................... 55. Study Design and Sample Population ................................................................... 55. U. 5.1 5.2. Interview Based Assessment ................................................................................. 56 5.2.1 Demographic Findings and General Health Status ............................... 56 5.2.2 Oral Health Related Knowledge, Attitude and Practices ...................... 60 5.2.3 Nutritional Assessment ......................................................................... 62. 5.3. Clinical Assessments ............................................................................................. 63 5.3.1 Oral Health Status ................................................................................. 63 CONCLUSION ..................................................................................... 70. xii.

(14) LIMITATIONS AND RECOMMENDATIONS ............................... 71 7.1. Study Limitations .................................................................................................. 71. 7.2. Recommendations ................................................................................................. 71. REFERENCES .............................................................................................................. 73. U. ni. ve. rs. ity. of. M. al a. ya. APPENDIX .................................................................................................................... 94. xiii.

(15) LIST OF FIGURES. Figure 2.1: Normal Anatomy of the Human Tooth......................................................... 19 Figure 2.2: Proximal Section Depicting Age-Related Changes of the Human Tooth .... 21 Figure 2.3: Age- Related Changes in the Periodontium of the Human Tooth ................ 24 Figure 2.4: Microscopic Appearance of Dentine Caries ................................................. 26. ya. Figure 2.5: Complete Edentulism ................................................................................... 28 Figure 3.1: MELoR Map ................................................................................................. 33. al a. Figure 3.2: WHO Adapted Form for Oral Clinical Assessment ..................................... 40. U. ni. ve. rs. ity. of. M. Figure 3.3: The Challacombe Scale ................................................................................ 42. xiv.

(16) LIST OF TABLES. Table 1.1: Population of the world according to medium-variant projections ................. 3 Table 3.1: Inclusion and exclusion criteria for the hospitalised participants .................. 34 Table 3.2 Inclusion and exclusion criteria for the non-hospitalised participants ............ 34 Table 4.1: Socio-demographic profile of the non-hospitalised and the hospitalised urban older adults ...................................................................................................................... 47. ya. Table 4.2: General health status of the non-hospitalized and the hospitalized urban older adults ............................................................................................................................... 48. al a. Table 4.3: Oral health related knowledge, attitude and practices between the nonhospitalised and hospitalised older adults ....................................................................... 49. M. Table 4.4: Nutritional status assessment of the non-hospitalised and the hospitalised... 50. of. Table 4.5: Dentition status of the non-hospitalised and the hospitalised urban older adults ............................................................................................................................... 51. ity. Table 4.6: Periodontal sextant status of the non-hospitalised and the hospitalised urban older adult ....................................................................................................................... 52. rs. Table 4.7: Challacombe scale status of the non-hospitalised and the hospitalised urban older adults ...................................................................................................................... 52. ve. Table 4.8: Factors related to denture wearing status ....................................................... 53. U. ni. Table 4.9: Predictors for decayed teeth of the study population ..................................... 54. xv.

(17) LIST OF SYMBOLS AND ABBREVIATIONS. :. Basic Periodontal Examination. BM. :. Bahasa Melayu. COPD. :. Chronic Obstructive Pulmonary Disease. CGA. :. Comprehensive Geriatric Assessment. MELoR. :. Malaysian Elders Longitudinal Research. MNA. :. Mini Nutritional Assessment. ya. BPE. National Oral Health Survey of Adults in Malaysia. PIS. Patient information sheet. U. ni. ve. rs. ity. of. M. :. al a. NOHSA :. xvi.

(18) CHAPTER 1: INTRODUCTION 1.1. Background. Twenty first century has faced an irreversible by-product of demographic transition referred to as “Population Ageing” (Kinsella & Velkoff, The demographics of agina, 2002). According to the World Population Prospects, the 2017 Revision, the world’s total population is numbered at nearly 7.6 billion, with sixty percent of the world’s. a. population is living in Asia (4.5 billion) (United Nations, 2017). The results of World. ay. Population Prospects, the 2017 Revision are summarized in Table 1.1. Survey statistics indicate that dwindling fertility rates and increased life expectancy contributed in part. al. by accessible health programs and refined health conditions, population in the age. M. bracket of 60 years or over is growing faster than all younger age groups (Pinelli, De Mattos Mda, Bezzon, & Ribeiro, 1998) (Samir & Lutz, 2017). Though, the phenomenon. of. of ‘Population Ageing’ is well accepted and publicized in the developed nations, the. ty. cause of concern today is the steeply rising pace of ageing in developing nations. si. (National Research Council, Committe on Population, 2001). With 80% of the older population residing in developing nations, it has become a tremendous challenge for the. ve r. health and social policy planners because of the contemporaneously shifting disease patterns. The health implications of ageing need to be thoroughly decoded, better. ni. exemplified and understood (Issrani, Ammanagi, & Keluskar, 2012). Throughout. U. lifespan, oral health is integral to general health and quality of life (Steele et al., 2004). Globally, poor oral health among older people is reported as having either or a combination of these issues such as high level of tooth loss (Natto, Aladmawy, Alasqah, & Papas, 2014), dental caries experience (Holm-Pedersen, Schultz-Larsen, & Avlund, 2008), high prevalence rate of periodontal disease (Eke, BA, Wei, Thorton-Evans, & Genco, 2012), xerostomia (Edgar, O'Mullane, & Dawes, 2004), and oral precancer/ cancer (Gonsalves, Wrightson, & Henry, 2008). It is further reported that oral health,. 1.

(19) diet and nutrition are found to be closely linked (El Osta, Hennequin, Tubert-Jeannin, Naaman, El Osta, & Geahchan, 2014). Impaired oral health could lead to disability (Yu, Lai, Cheung, & Kuo, 2011), weaker handgrip strength (Hämäläinen, Rantanen, Keskinen, & Meurman, 2004), lower nutrient intake (Andrade, Caldas Junior, Kitoko, & Zandonade, 2011) and weight loss (Lee, et al., 2004). The cumulative burden of oral health problem has been shown to have considerable social impact on older people’s. a. daily life, ranging from minor pain and discomfort to severe limitation in performing. ay. everyday activities. This interferes with an individual’s capacity to chew, bite, speak, smile, and negatively influences one’s psychosocial well-being (Yap, 2017). Likewise,. al. the above mentioned factors can also be attributed as a consequence of an individual’s. M. educational, economic, dietary, psychological, cultural, and chronologically specific cohort experiences (John, Mani, & Azizah, 2004). Despite the stated, the older people. of. are considered as scapegoats for rising healthcare costs neglecting the quantification of. ty. the actual burden of dental diseases. The sphere of importance for the older members of. si. society is provision of good quality of life through intergenerational relationship and it. ve r. is the need of the hour worldwide (Saxena & Yadav, 2011).. Malaysia, in the past decade, has undergone a diametric shift in the demographics. ni. towards being an ageing nation. Longer life expectancy, declining mortality and fertility. U. rates are contributing factors for this apparent shift (Hamid, 2015). Although, the escalation in the proportion of its ageing population is not as phenomenal as in countries such as China and Singapore, it is notably rapid and huge. Such increase in the proportion of older people would make it impossible for the government to ignore the marked effect on social and economic changes which will be brought about by population ageing (United Nations, 2017).. 2.

(20) Survey statistics indicate that with an upward trend in the ageing population, the number of adults with multifarious health issues is increasing (World Population Ageing, 2009). The dentition status in the older population has seen a change in trend from denture wearing towards the retention of natural teeth, the need for various types of dental services continues to increase (Emami, de Souza, Kabawat, & Feine, 2013). Compromised oral health is one of many barriers to achieve holistic health in older age.. a. Several regional based studies, for instance, the study conducted in Kelantan to evaluate. ay. the dental caries experience living in “Pondok” indicated that dental caries status of elderly people was unsatisfactory with high percentage of edentulism, contributing to. al. the high value of the mean DMFX(T) index 29.3 (SD 6.63) (Seman, Manaf, & Ismail,. M. 2007). Likewise, a high prevalence of edentulism 55.9% was reported in elderly Muslim females in Kota Baru, Kelantan, Malaysia (Shamdol, Ismail, Hamzah, & Ismail, 2008).. of. Therefore, optimization of an individual’s oral health is important.. si. ty. Table 1.1: Population of the world according to medium-variant projections Population (millions). Region. 2030. 2050. 2100. World. 7550. 8551. 9772. 11184. Africa. 1256. 1704. 2528. 4468. Asia. 4504. 4947. 5257. 4780. Europe. 742. 739. 716. 653. Latin America and the Caribbean. 646. 718. 780. 712. Northern America. 361. 395. 435. 499. Oceania. 41. 48. 57. 72. U. ni. ve r. 2017. Source: United Nations, Department of Economic and Social Affairs, Population Division (2017). World Population Prospects: The 2017 Revision. New York: United Nations.. 3.

(21) 1.2. Aim of the Study. To compare the oral health and nutritional status between hospitalised and nonhospitalised urban elderly population.. 1.3. Research Objectives. The specific objectives of the current study are as stated below;. a. 1. To compare the oral health (dentition status, periodontal status, denture wearing. ay. status and salivation status) between the hospitalised and non-hospitalised urban elderly population.. al. 2. To compare oral health related knowledge, attitude and practices between. M. hospitalised and non-hospitalised urban elderly population.. 3. To compare the nutritional status between the hospitalised and non-hospitalised. of. urban elderly population.. ty. 4. To determine whether hospitalisation is one of the predictor of the dentition. Research Significance. ve r. 1.4. si. status.. The specific aim of our geriatric dental research was based mostly on two main. ni. groups of older adults:. U. 1. Community-dwelling functionally independent older adults. 2. Institutionalized functionally dependent older adults (hospitalized in the Geriatric Ward, UMMC).. There is limited knowledge on the oral health of the frail hospitalized versus the community -dwelling older people as they are unable to participate in epidemiological studies owing to age, compounded by issues of declining functional status and medical. 4.

(22) status, and other complications of declining cognitive status, reduced effective functioning, increased need for social support, increased caregiver burden, frequent hospitalizations and increased socioeconomic dependence. Moreover, barriers to dental care are encountered, like ease of accessibility to dental clinics; treatment costs, lack of basic dental screenings upon hospitalization, difficulty in establishment of set ups in the geriatric wards for the provision of basic dental treatment and oral health education by. a. trained dental staff. Studies have revealed that most community-dwelling functionally. ay. independent older adults have generally good oral health whilst they can access dental services; however, individuals who are at higher risk for some oral diseases and. al. conditions, include functionally dependent individuals with dementia, Parkinson’s. M. disease and chronic mental illness (Chalmers, Carter, & Spencer, 2003).. of. As foreseen, an increase in percentage of the institutionalized and/ or noninstitutionalized older population will result in Malaysia becoming an ageing nation by. ty. the year 2020. As estimated, 9.8% of the entire population will be in the elderly. si. bracket. This is a clear indication of the crucial need to learn about the oral health of the. ve r. aging population and its consequences. It is hoped that the outcome of this research will channel to assist the oral health care providers to offer enhanced oral health care for the. ni. older sector of the society. It is henceforth imperative to tend to the goal of ‘Successful. U. Ageing’ whereby, he/she can maintain healthy oral tissues and natural functional dentition throughout his/her remaining adult life with all the social and biological benefits such as aesthetics, comfort, ability to chew, swallow, taste, speak competently and be free from oral pain.. 1.5. Null Hypothesis. The null hypothesis of the study was:. 5.

(23) •. No difference is expected to be present in the oral health (dentition status, periodontal status, denture wearing status and salivation status) between hospitalised and non-hospitalized urban elderly population.. •. There is no expected difference in the oral health related knowledge, attitude and practices between hospitalised and non-hospitalised urban elderly population.. •. No difference is expected in the nutritional status between hospitalised and non-. a. hospitalised urban elderly population. •. ay. Field of Research. al. 1.6. Hospitalisation will not be one of the predictor of the dentition status.. M. “Geriatric Dentistry or Gerodontics is the delivery of dental care to older individuals involving the diagnosis, prevention, and treatment of problems associated with normal. of. ageing and age-related diseases as a part of an inter-disciplinary team with other health. U. ni. ve r. si. ty. care professionals” (Issrani, Ammanagi, & Keluskar, 2012).. 6.

(24) LITERATURE REVIEW 2.1 Ageism and Ageing: Framework The perception of ageing has changed throughout the history. In the year 1969, Robert Butler, first director of the National Institute of Ageing, a division of the U.S. National Institutes of Health, located in Maryland, coined the term “Ageism”; defining it as a process of systematic stereotyping and discrimination against people because. a. they are old (Scully, 2000). Ageism can be distinctly categorized into two contexts,. ay. based on beliefs about the impact of biological ageing on people of all ages. Firstly, the. al. chronological age, the numbers used for employment retirement, celebrating birthdays to maintain social identity (Gilliard & Higgs, 2000). Secondly, as defined by Butler,. M. ageism is like sexism and racism is used to discriminate old people from the younger. of. population who categorize them as senile, rigid, old-fashioned, inferior, and so on (Bytheway, 2005). Therefore, ageism is established in the social personality of the. ty. individual, both a bureaucratically overseen character and a character passed on by the. si. physical appearance of the body (Bytheway, 2005). Numerous terms have since been. ve r. used by researchers to describe people considered old, but they also acknowledge the immense diversity inherent to this term (Saxena & Yadav, 2011). Moreover, all. ni. societies use age, sex, economic status, and ethnicity to classify individuals (Johnson,. U. 1995).. In entirety, albeit thoughtfully the contribution of age generalization in age. separation is inescapable, the negligible actuation of age generalizations is in no way, shape or form an adequate condition for the event of age segregation. A full comprehension of the complexities of these relations requires structures that consolidate logical imperatives and furthermore consider the area of age generalizations and age segregation (Ayalon & Tesch-Romer, 2018).. 7.

(25) The term “Ageing” can be defined in numerous ways. One way to define ageing is as “a natural biological, pathological, psychosocial or a socioeconomic process” (Kalk & Meeuwissen, 1992). The United Nations describes an “ageing population as a decline in the proportion of children and young people and an increase in the proportion of people aged 60 years and above” (World Population Ageing, 2009). The ages of 60 and 65 years have repeatedly been adopted as the beginning of old age despite the fact, the. a. definition of ageing varies across cultures, countries and time, (Kinsella & Velkoff,. al. 2.2 Age- categorization of the Elderly Population. ay. 2002).. M. According to the definition laid down by the UN, older or elderly persons are defined as having attained 60 years of age. Within the elderly population, further classification. of. like oldest old (normally those 80+) and centenarian (100+) and even super-centenarian. ty. (110+) are also made (United Nations, 2015).. Conventionally, chronological age of 65 years and above has been used to describe. si. “elderly”. Under this classification, 65 through 74 years old are referred to as “early. ve r. elderly” whereas, those over 75 years old are termed as “late elderly”. There is insufficient evidence to support this finding (Orimo, Ito, Suzuki, Araki, Hosoi, &. U. ni. Sawaba, 2006).. Older adults can also be classified into three groups based on functional living. ability; functionally-independent, frail and functionally-dependent (Yeh, Katz, & Saunder, 2008).. According to the concept of ageism, old people are categorized as senile, rigid in thought and manner, old-fashioned in morality and skills. However, like racism, the. 8.

(26) concept of ageing should not be validated as negative stereotyping keeping in mind the factors of frailty, social isolation, physical, and economic dependence (Jonathan, 2008).. 2.3 Population Ageing According to the report published by U.S. Census Bureau in 2010, the number and proportion of world’s older population has been increasing for the past so many generations (US Census Bureau Report, 2010). However, the twenty first century has. a. faced the challenge of ageing, popularly termed as “Population Ageing” (Kinsella &. ay. Velkoff, The demographics of agina, 2002). According to this concept, the overall. al. health of an individual is both determined by and contributes to broad social trends of. M. globalizing economies, rapidly evolving technology, and transforming family patterns (WHO, 2012).. of. Along with this phenomenon and other factors, ubiquitously, there has been an. ty. unprecedented growth in the number and proportion of people who live to see their 80’s. si. or 90’s than ever before. The World Health Organization (WHO) guidelines classify a country's population as an ageing population when the population aged 65 and 65+. ve r. year’s reaches 7.0 % of its total population (WHO, 1989). Malaysia has adopted the United Nations definition of those aged 60 years and above (60+ years) for “older. ni. people” as opted by various developing countries belonging to ASEAN community. U. (Cohen, 2003).. Globally, the population of older persons is increasing at a rate of 2.6 % per year (World Population Ageing, 2009). It is expected that by the year 2050, the older population is expected to continue grow more rapidly than the population in other age groups. Improvement in life expectancy has been brought about in part by improved health conditions and more accessible health programs, and reduced fertility and. 9.

(27) mortality rates (Mafauzy, 2000). The rise in older cohort will thereby, require farreaching economic and social adjustments in most countries. However, it is also of interest that marked differences exist between developed and developing regions in the number and proportion of the older persons. In the more developed countries, over a fifth of the population is currently aged 60 years or over and by 2050, nearly a third of the population in the developed countries is projected to be in that age group (Shetty,. a. 2012). Worldwide, the percentage of the population aged 60 years or over increased by. ay. 3 points between 1950 and 2009 from 8 to 11 %. Also, it is expected that by the middle of the 21st century, the percentage would increase by 11 percentage points, to 22 per. al. cent (World Population Monitoring & Development, 2008). Likewise, for Malaysia, the. M. population has almost quadrupled in the past five decades, growing to 27.4 million in the year 2010 from 7.4 million in 1957 (Population & Demography Division, 2017).. of. According to the Malaysian Population and Housing Census 2010, 3.3 percent of the. ty. population was aged 65 years and over in the year 1970, and almost half of the. si. population (44.5%) was under the age of 14 years. However, in the year 2017, children accounted for less than one-fourth of the total population (24.1%), while those aged 65. ve r. years and over comprised 6.2 per cent of the total population. It is estimated that Malaysia is expected to have nearly equal share of the young (18.6%) and older. ni. population (14.5%) by the year 2040. Statistically, this will account for three older. U. persons for every 20 people (Population & Housing Census, 2010). Changes in the Malaysian population age structure can further be described as follows: in 1957, the shape of the population pyramid was progressive with a broad base, concave slope, and sharp peak. In 2010, the shape of the pyramid was regressive with a smaller base indicative of low birth rate and a convex slope reflective of low mortality rates of the adult population. The apex being flat and wide indicative of higher percentage of the. 10.

(28) elderly population and is expected to remain as such until 2040 (World Population Monitoring & Development, 2008).. 2.4 Ageing Index A concept that represents the number of people aged 65 years and older for every 100 individuals aged 15 years and less. A country having a low ageing index will be having smaller proportion of older individuals at a point in time and concurrently. a. having large number of young’s. The scenario is reverse if the country has a higher. ay. ageing index (Wan-Ibrahim & Zainab, 2014). According to the 2008 International. al. Population Reports, aging index was highest in Europe and lowest in Africa and the. M. Near East (Kinsella & Wan, An aging world: 2008, 2009). Malaysia too is seeing a rise in the number of baby boomers with a progressive increase in the ageing index from. of. 10.5 in 1957 to 11.6 in 1970 further to 14.6 in 1980 and an estimated value of 18.2 in 2000 (Department of Statistics, Malaysia, 2005) (Oral Health Division, Ministry of. ty. Health, 2010).. ve r. si. In tandem with the phenomenon of population ageing, Malaysia’s population is rapidly changing in size, composition, and distribution. The changing demographics pose the need to accurately and expeditiously assess and analyze the relationship of this. U. ni. trend with national policy development and implementation.. 2.5 The Impact of Aging on Oral and General Health 2.5.1 Aging and General Health. Our world is on the brink of a demographic transition. With improved living conditions, better hygiene and advances in medical care people are aging but often with multiple, debilitating, and chronic mental and physical conditions (World Population Ageing, 2009). Socio-economic development has brought about a transition from high. 11.

(29) to low mortality and fertility rates bringing about a shift in the leading causes of disease and death. Demographers and epidemiologists describe this transition as part of an “epidemiologic transition” which is characterized by the waning of infectious and acute diseases and the emerging importance of chronic and degenerative diseases (WHO, 2015).. 2.5.2 Oral Health and General Health. a. Oral health is well recognized as an integral part of general health and although not. ay. life-threatening or seriously impairing for older adults, can affect quality of life and the. al. management of medical conditions (Petersen & Yamamoto, 2005).. M. The concept of having good oral health has evolved from just excellent oral. of. functioning of teeth so that all individuals can (Shay & Ship, 1995):. Eat and talk comfortably. •. Feel happy about their appearance. •. Maintain social interaction and self-esteem. •. Stay pain free. •. Maintain habits/standards they have had throughout their life. •. To lead a balanced healthy lifestyle. ni. ve r. si. ty. •. U. The state of health of the oral cavity can also impact the course and pathogenesis of. several systemic conditions.. 2.5.3 Pulmonary Diseases. Pulmonary diseases such as pneumonia, chronic obstructive pulmonary diseases (including emphysema), and exacerbations of chronic bronchitis (all involve oral pathogens especially those that are blood-borne or the aspiration of bacteria from the oropharynx into the lower respiratory tract) (Amar & Han, 2003). The human oral. 12.

(30) cavity hosts a highly diverse microbial flora. Because of its humidity and temperature, the mouth provides an appropriate environment for the development of organized bacterial communities. These occur as biofilms on both hard surfaces (teeth) as well as the soft tissue of the stomatognathic system (Sachdeo & Socransky, 2008). It should be emphasized that these communities are complex organizations and include a wide variety of different species of bacteria with varying degrees of virulence (Albert, Spiro,. a. Jett, & R, 1999). An infection occurs when the host’s defense system is compromised,. ay. the pathogen is particularly virulent or the inoculum is overwhelming. The microorganisms may enter the lung by inhalation, but the most common route of infection is. al. aspiration of what pneumologists have long referred to as oropharyngeal secretions. M. (Filho, Passos, & Cruz, 2010).. of. 2.5.3.1 Atherosclerotic Diseases (Coronary Heart Diseases and Cerebrovascular. Diseases). ty. Atherosclerotic diseases occur due to pathological narrowing of arteries because of. si. accumulation of cholesterol and cholesterol products in vessel walls (Scannapieco,. ve r. 2005). Several studies have reported that periodontal disease and poor oral hygiene tend to have a strong association with the risk of coronary heart disease and acute myocardial. ni. infarction. However, there is insufficient evidence to prove a causal link between them. U. (Kuo, Polson, & Kang, 2008). On the other hand, there is better and substantial evidence to support the causal relationship between poor dental health and cerebrovascular disease (Scannapieco, 2005).. Patients presenting with signs and symptoms of poor oral hygiene, frequent and severe gingival inflammation and frequent bacteremia (periodontal disease) will have an activated host inflammatory response (Amar & Han, 2003), (Pihlstrom, Michalowicz, & Johnson, 2005) (Kuo, Polson, & Kang, 2008). This chronic inflammatory state will. 13.

(31) trigger multiple pro-inflammatory cytokines, such as C-reactive protein, tumor necrosis factor α, interleukin 1β, and interleukin 6, which in conjunction with bacteremia and in turn stimulate the process of atherogenesis as well as increase the susceptibility of the vascular endothelium for injury (a precursor to atherogenesis). Moreover, during such episodes of dental bacteremia, streptococci of the viridans group tend to induce platelet aggregation and possibly thrombus formation (Nakajima, et al., 2010). Atherosclerotic. a. cerebrovascular disease plays a major role in the etiology of cerebrovascular accidents. ay. (strokes) and transient ischemic attacks (Pihlstrom, Michalowicz, & Johnson, 2005) ,. al. (Kuo, Polson, & Kang, 2008).. M. 2.5.3.2 Diabetes Mellitus. Disrupted glycemic control results from a lack of insulin production (type 1) or. of. systemic insulin resistance (type 2) (Kuo, Polson, & Kang, 2008). It was estimated in the year 2008 that 18 million people worldwide had diabetes. The relationship between. ty. diabetes and periodontitis is bidirectional, whereby, severe periodontitis can negatively. si. impact glycemic control and vice versa (Garton & Ford, 2012). Advanced glycation end. ve r. products have a systemic impact that results in the increased excretion of cytokines. This leads to local inflammation and loss of connective tissues. Glycemic control is. ni. more difficult in the presence of local inflammation in the mouth, this in turn, increases. U. the risk of infection in the form of systemic effects- explaining the bidirectional relationship of the condition (Amar & Han, 2003). Prolonged hyperglycemia has been reported to have negative effects on the heart, eyes, kidneys, and peripheral nerves, and studies now suggest that periodontal disease should be considered as a major complication of diabetes (Lamster, Lalla, Borgnakke, & Taylor, 2008), (Petersen, Bourgeois, Ogawa, & Ndiaye, 2005).. 14.

(32) 2.5.3.3 Osteoporosis. An imbalance between bone loss and formation leads to decreased bone mineral density. This decreased density in the jawbone leads to greater alveolar bone resorption, increasing the depth and number of gingival pockets, which in turn allows invasion by periodontal pathogens (Kuo, Polson, & Kang, 2008). Furthermore, in the recent times, studies have supported a positive bidirectional relationship between periodontal health. a. and osteoporosis but still there is lack of evidence to back this argument (Amar & Han,. ay. 2003) (Kuo, Polson, & Kang, 2008).. al. 2.5.3.4 Chronic Kidney Diseases. M. Poor periodontal health lead to systemic inflammation, infection, protein wasting, and the development of atherosclerotic lesions, all of which worsen morbidity and. ty. 2.5.3.5 Nutritional Status. of. mortality in chronic kidney disease patients (Kuo, Polson, & Kang, 2008).. si. Nutrition and oral health have a synergistic relationship. Studies have indicated that. ve r. impaired oral health is related to disability (Holm-Pedersen et al., 2008), weaker handgrip strength (Hämäläinen et al., 2004), lower nutrient intake (Andrade et al., 2011) (Tsakos, Herrick, Sheiham, & Watt, 2010) and weight loss (J. S. Lee et al., 2004). ni. (Ritchie, Joshipura, Silliman, Miller, & Douglas, 2000). According to the literature,. U. these factors are significantly associated with the pathogenesis of frailty (Fried et al., 2001) which is a term used to denote a multidimensional syndrome involving the loss of reserves (energy, physical ability, cognition and health) that give rise to vulnerability (Rockwood et al., 2005) and is significantly related to mortality (Buchman, Wilson, Bienias, & Bennett, 2009) (Masel, Ostir, & Ottenbacher, 2010). Furthermore, studies suggest that people with a well maintained natural dentition have better nutritional intake than those with full dentures, and those with well-fitting dentures have better. 15.

(33) nutritional intake (Suzuki et al., 2005) than those who have either ill-fitting dentures or none at all (Moynihan et al., 2009).. Nutrition is a vital determinant of health in the older population. Over the past decade, the significance of nutritional status has been recognized in a range of morbidities such as cancer, coronary heart disease, and dementia in individuals over the age of 65 (Van, Guedon, Maniere, Manckoundia, & Pfitzenmeyer, 2004). Malnutrition. a. is usually identified in the elderly on the basis of some common indicators which. ay. include involuntary weight loss, atypical body mass index (BMI), specific vitamin. al. deficiencies, and lowered dietary intake (Rubenstein, Harker, Salvà, Guigoz, & Vellas,. M. 2001). Malnutrition in older individuals is often underdiagnosed (Gariballa, 2000). For instance, health practitioners may additionally no longer readily understand weight loss. of. in the aged as a morbid symptom of malnutrition because some weight loss might also be associated with age-related discounts in muscle mass (Kane et al., 1994). Similarly,. ty. elderly patients with concurrent obesity often have protein under nutrition that also goes. ve r. si. undiagnosed (Wells & Dumbrell, 2006).. Although the prevalence of malnutrition among elderly people living in the. community is reported to be between 2% and 16%, up to 55% of elderly people. ni. admitted to hospital have pre-existing proof of malnutrition (Wells & Dumbrell, 2006).. U. The incidence of protein under nutrition in geriatric rehabilitation is estimated at 57%, not including patients with micronutrient deficiencies (Chandra, 2002). Through their hospital stay, in addition to pre-existing malnutrition, hospitalised patients also experience new nutritional problems like nausea, "nothing by mouth" orders, side effects of medication, vision problems, limited access to snacks and ethnic or religious food preferences all adding up to poor nutritional intake (Milne, Potter, Vivanti, & Avenell, 2009).. 16.

(34) Malnutrition is also associated with increased duration of stay, readmission, mortality, skin breakdown, and infection during hospitalization. Compromised nutritional status could also be associated with reduced immunity, breathing and muscle control, and delays in wound healing (Pichard et al., 2004).. In addition to understanding dietary concerns, current medical research confirms the value of executing a treatment plan promptly. Typically, physical examination does not. a. help detect early malnutrition in the elderly, as some of the muscle bulk loss may be due. ay. to age-related processes. However, changes in the nail, hair, tongue and angle of the. al. mouth could be due to specific nutrient deficiencies. These findings combined with. M. biochemical studies such as laboratory tests examining complete blood counts with differential, albumin, ferritin, electrolytes, blood urea nitrogen, fasting glucose, and. of. creatinine can provide an objective measure of nutritional status (Reuben et al., 2004).. ty. The Mini-Nutritional Assessment (MNA) is the most commonly used and widely. si. accepted screening tool used by physicians. It contains six questions and is strongly. ve r. correlated with total MNA score (r = 0.945), and is applicable for both community dwelling and hospitalised elderly (Ranhoff, Gjoen, & Mowe, 2005). Another simple office measuring tool designed to identify older people’s malnutrition is the Body mass. ni. index (BMI= weight in kilograms (kg)/height in meters (m)2). A suitable height estimate. U. is arm length in the elderly. Regular weight monitoring is a quick but effective way to monitor malnutrition during office appointments (Corish, Flood, & Kennedy, 2004). The SCALES evaluation (Nutritional Screening Initiative 2005) is another easy-toperform mnemonic screening tool. This requires physicians to evaluate older patients with respect to: sadness (depression); levels of cholesterol; albumin (serum levels < 40 g / L); weight loss; eating problems (cognitive and/or physical determinants); and shopping problems or inability to prepare meals. A problem with three or more of these. 17.

(35) areas indicates a high risk for malnutrition. Another method is the "Determine Your Nutritional Health Checklist," which in the community setting can be a very useful tool (Nutritional Screening Initiative, 2005). Nevertheless, because it focuses on selfreporting, it may be of limited use for seniors with cognitive impairment or poor vision. A validated tool in the nursing home setting is the amount of food left on the plate of a resident. People who have more than 25% of their food on their plate are most likely to. a. suffer from protein under nutrition (Beck, Ovesen, & Schroll, 2001).. ay. 2.5.3.6 Xerostomia (Dry Mouth). al. Saliva is a salient component in the maintenance of oral health and thereby, general. M. health. It acts as a source of ions facilitating re-mineralization of calcified tissues, offering physiological and immunological protection (Edgar et al., 2004). Dry mouth. of. hampers eating, swallowing and putting on dentures thus, leading to taste modifications, ulcerations of the oral mucosa, burning sensation of the oral mucosa and inferior oral. ty. hygiene (Stookey, 2008). Dry mouth can be triggered by numerous causes such as,. si. dehydration, medication, chemotherapy and radio therapy, salivary gland diseases and. ve r. aging of human body (Sreebny, Valdini, & Yu, 1989). A reduction in the amount of saliva and the characteristic of saliva exposes the oral cavity to the ill effects of. ni. microorganisms causing several oral infections such as caries, gingival inflammation,. U. angular chelitis and candidiasis (Greenspan, 1996).. Also, there is the group of older people who may multiple underlying co-morbidities. but are retaining natural teeth with dental diseases requiring various ranges of curative and rehabilitative treatment (John et al., 2004).. 18.

(36) 2.5.4 Ageing and Oral Health. Dental longitudinal investigations (Kowal et al., 2012) (Murray, 2014) of older adult populations have improvised our database pertaining to the natural history and prevention of oral diseases. It indicates that all oral conditions are not true ‘aging’ changes in all older adults, reflecting both the accumulation of oral diseases over time and the influence of factors such as stress, trauma, medications, and psychological. For. a. example, ‘age-related’ changes in the oral cavity would include coronal caries, root. ay. caries and periodontal diseases, conditions such as tooth-loss and oral mucosal problems, reflecting both the accumulation of oral diseases over time and the influence. al. of factors such as stress, trauma, medications, and psychological, neurological and. U. ni. ve r. si. ty. of. normal anatomy of the human tooth.. M. medical conditions (Razak et al., 2014). A picture as shown in Figure 2.1 depicts the. Figure 2.1: Normal Anatomy of the Human Tooth (https://www.pinterest.com/pin/546694842250032145/). 19.

(37) 2.5.5 Age Related Dental Changes 2.5.5.1 Teeth. Some aging changes occur in terms of the Appearance of teeth (Guiglia et al., 2010). A. ‘Shortening’ of the tooth crown may occur due to occlusal attrition. The perikymata and imbrication lines are lost, giving the enamel surface a flat appearance with less. a. detail than in newly erupted teeth.. ay. B. Teeth darken, become ‘yellower’ and are less translucent because of:. al. B.1. Decreased enamel permeability, altering the optical density of the enamel; and. M. B.2. Increased ‘thickness’ of dentine, changes in the type of dentine and dentine. of. sclerosis resulting from sedimentation of crystals.. B.3. Pigmentation of anatomical defects, corrosion products and inadequate oral. si. ty. hygiene are contributing factors too (Chalmers, Carter, & Spencer, 2003).. ve r. Physiological Changes: The changes in Enamel are based on ion-exchange mechanisms. With age, it becomes less permeable and more brittle with age and the nitrogen content of enamel is expected to increase (Atsu, Aka, Kucukesmen,. ni. Kilicarslan, & Atakan, 2005). For Dentin, two-age change takes place; continued. U. growth, referred to as physiological secondary dentin formation and gradual obturation of the dentinal tubules referred to as dentin sclerosis. The Dental Pulp of older individuals has more fibers and lesser cells, and hence reduced volume. Reduction of blood supply especially in the region of subodontogenic plexus is observed (Morse, Esposito, Schoor, Williams, & Furst, 1991). These changes in turn attribute to the low reparative capacity of the pulp as compared to younger teeth. Electron microscopy of the old pulps reveals loss and degeneration of both myelinated and unmyelinated nerve. 20.

(38) fibers affecting the healing capacity of the pulp. Pulp calcification (number and size), diffuse calcifications and narrowing of the root canals are found to increase with age. With age, rate of formation of Cementum diminishes but cases of hypercementosis (excess amounts of Cementum) are reported as well. This could be associated with accelerated elongation of an unopposed tooth or to an inflammatory stimulus. Furthermore, increase in the fluoride and magnesium content is seen with age (Morse,. a. 1991) (Fejerskov, Larsen, Richards, & Baelum, 1994).. ay. The age changes as shown in Figure 2.2 have important clinical repercussions as. al. they impact/ influence the outcomes of restorative treatments and reparative responses.. M. The dentist need to keep in mind the design of cavity preparations for an ageing tooth; the choices of restorative materials; anatomy and aesthetic appearance of final. of. restoration. Even the radiographic interpretation and diagnosis requires expertise (John. U. ni. ve r. si. ty. et al., 2004).. Figure 2.2: Proximal Section Depicting Age-Related Changes of the Human Tooth (https://www.studyblue.com). 21.

(39) 2.5.5.2 Oral Mucous Membrane. With age, a decline in protective barrier function of the oral mucosa could expose the host to an army of pathogens and chemicals that could enter the oral cavity during daily activities. The epithelium, and the connective tissue which form the two histologic layers of the oral mucosa, are reported to have important defensive functions. The stratified epithelium, which is made up of closely apposed, attached cells, constitutes a. a. physical barrier that interferes with the entry of toxic substances and microorganism.. ay. Mucosal epithelial cells also synthesize several substances that are critical for. al. maintenance of the mucosal surface, such as keratin and laminin (Friedman, 2014).. M. Also, it is reported that the oral mucosa becomes increasingly thin and smooth with age and that it acquires satin like edematous appearance with loss of elasticity and. of. stippling. In particular, the tongue is reported to show marked clinical changes becoming smoother with loss of filiform papillae. The tendency for development of. ty. sublingual varices and increased susceptibility to various pathological conditions such. si. as candidal infections and decreased rate of wound healing is shown to increase with. ve r. age (Papas, Niessen, & Chauncey, 1991).. Dentists need to evaluate the oral mucosal status in older persons for the use of. ni. prosthetic appliances, which has considerable potential to alter mucosal integrity if not. U. maintained properly.. 2.5.5.3 Periodontitis. In the older people, periodontal issues do not appear to be specific disease but the result of a chronic periodontitis from adulthood (Jin, Chiu, & Corbet, 2003). Agerelated changes have been reported in the periodontium of older people as shown in Figure 2.3; these changes however, do not appear to be the cause of periodontal. 22.

(40) diseases. Increased severity of periodontal diseases with age has been attributed to the length of time the periodontal tissues have been exposed to the dento-gingival bacterial plaque and is considered reflective of the individual’s cumulative oral history. However, the susceptibility of the periodontium to plaque-induced periodontal breakdown may be influenced by the aging process or by a specific health problems of the aging patient (Rattan & Kassem, 2007).. a. In older people, at the biological level, changes in structure and function during. ay. aging may affect the host response to plaque microorganisms and may influence the rate. al. of periodontal destruction. In the older people, recovery of plaque in greater amounts. M. could be in part, to a larger area for plaque retention because of the gingival recession. Furthermore, the exposed cementum of the root surface and dental enamel influence the. of. plaque formation rate as they constitute two unlike types of hard dental tissues with distinct surface characteristics. Variations in dietary habits, increased flow of gingival. ty. exudate from the inflamed gingiva and possible age-related changes in salivary gland. si. secretions may also alter the conditions for growth and multiplication of the plaque. ve r. microorganisms (Razak et al., 2014).. Epidemiological surveys have reported that the prevalence and severity of. ni. periodontal diseases increase with age and the Community Periodontal Index score of 4. U. (deep pockets) ranges from approximately 5-70% among older people (WHO, 2007). Figure 2.3 reflects some of the age-related changes of the human tooth.. 23.

(41) a ay al M. Figure 2.3: Age- Related Changes in the Periodontium of the Human Tooth. of. (https://medical.azureedge.net) 2.5.5.4 Changes in the Salivary Gland and Secretion. ty. Saliva protects the oral cavity, the upper airway and digestive tract and facilitates. si. numerous sensorimotor phenomena. Therefore, the absence of saliva has many. ve r. deleterious consequences to the host. Aging is associated with atrophy of acinar tissue, a proliferation of ductal elements and some degenerative changes in the major salivary. ni. glands. The changes in the gland and its tissue take place linearly with increasing age. It. U. is reported that minor salivary glands also undergo similar degenerative changes with advancing age. This eventually leads to a normal, uniform decrease in the acinar content of salivary gland tissue accompanying the aging process (Vissink, Spijkervet, & Amerongen, 1996).. With advancing age, degradation of quality and decrease in quantity of saliva pre disposes the oral cavity to the action of microorganisms leading to various oral. 24.

(42) infections such as caries, gingival inflammation, angular chelitis and candidiasis (Greenspan, 1996).. 2.5.6 The Incidence of Oral Diseases and Conditions. In the present day and age, the oral health of elderly people is far from optimal. Their treatment needs per se are high due to conditions like edentulism, missing teeth, caries, periodontal diseases and attrition resulting in impaired oral function and in turn,. a. affecting their quality of life (Ramli et al., 2002). Successive cohorts of older adults are. ay. maintaining a greater proportion of teeth into later years whilst continuing to share their. al. unequal burden of problems arising from tooth loss. Therefore, this new cohort of the. M. older population is expected to be highly critical and more demanding when it comes to oral healthcare services (Dolan & Atchison, 1993).. of. 2.5.6.1 Caries. ty. Dental caries or tooth decay clinically is defined as a lesion extending beyond the. si. surface of enamel or cementum. It could affect the coronal as well as the roots of the. ve r. teeth (Saunders & Meyerowitz, 2005). The etiology of caries is through a complex interaction over time between acid-producing bacteria and fermentable carbohydrate, and the host factors including teeth and saliva. Risk factors for caries include physical,. ni. biological, environmental, behavioural, and lifestyle-related factors such as high. U. numbers of cariogenic bacteria, inadequate salivary flow, insufficient fluoride exposure, poor oral hygiene, chronic medical conditions, cognitive deficits due to mental illness, depression, Alzheimer's disease or dementia, Sjögren's syndrome (an autoimmune disease), multiple medication use, diminished manual dexterity due to stroke, arthritis, or Parkinson's disease, diabetes, Radiation treatment for head and neck cancer and poverty (B Gupta, 2006) (Selwitz, Ismail, & Pitts, 2007). Dental caries experience is measured by the mean number of Decayed, Missing and Filled Teeth index (DMFT) (P.. 25.

(43) Petersen et al., 2010). The incidence of primary coronal caries in the older adults is not high but secondary coronal caries and root surface caries do have a high prevalence (Banting, Ellen, & Fillery, 1980).. For developed nations like United States of America, England, Denmark, New Zealand, Norway and Sweden a decline in the caries prevalence has been reported in the last part of the 20th century. According to the WHO databank for developing countries. a. an increase in caries severity has been reported with DMFT ranging from 1.6 to 10.4. ay. over periods of 9-50 years (Krishna Madhusudan, 2010). For the Malaysian Adults. al. according to NOHSA 2010, there has been a declining trend in caries prevalence with. M. 95%, 94.6% and 90.3% of adults experiencing caries in first, second and third adult epidemiological surveys respectively. For the 65-74 year age group, mean D index was. of. 1.55 (95%CI:1.29-1.81); mean M index was 22.14 (95% CI:21.09-23.18), mean F index was 0.66 (95% CI:0.42-0.91 and mean DMFT was 24.35 (95% CI: 23.49-25.21) (Oral. ty. Health Division, 2010). Figure 2.4 depicts the microscopic progression of dentinal. U. ni. ve r. si. caries.. Figure 2.4: Microscopic Appearance of Dentine Caries. 26.

(44) (https://www.google.com/dentinalcaries). 2.5.6.2 Tooth Loss and Edentulism. With increasing age, relatively more teeth are lost. Complete edentulism as shown in Figure 2.5 is a state of complete tooth loss described as the final marker of the burden of diseases for the health of the oral cavity (Cunha-Cruz, Hujoel, & Nadanovsky, 2007). Edentulism could be partial or complete. Edentulism was commonly reported in the. a. older adults; however, in the present scenario growing number of people manage to. ay. retain their natural dentition into old age. The status of edentulism in Malaysia is greatly. al. influenced by the historical pattern of oral health care practiced during the 19th century. M. especially in the United Kingdom, when tooth extraction was perceived as an acceptable, and a preferred approach having left a legacy of edentulism among the. of. Malaysian elderly (Ramli et al., 2002). Dental caries and periodontal disease are considered the major risk factors for tooth loss and in turn significant component of the. ty. global burden of oral disease (WHO, 2006). The risk factors for edentulism are. si. influenced by the interaction between dental diseases, attitude towards dental health,. ve r. socioeconomic status, lifestyle and habits (Amarasena et al., 2003).. It has been reported that the prevalence rate of edentulism is high (35%) in upper-. ni. middle income countries, but currently low (10%) in low income countries (Bank.,. U. 2010). Data from NOHSA 2010 shows a trend of decline in the incidence of edentulism with increasing age from 11.8% in 1974/75, 10.4% in 1990, and 8.8% in 2000. Tooth mortality is a major problem among older people in Malaysia with 32.2% of individuals in the 65-74 years old age group reported as edentulous (Oral Health Division, 2010). Compared to the change observed in adult surveys, there is not much marked improvement. The proportion of edentulous adults decreased from 28% in 1978 to 6% in 2009 for England (The NHS Informartion Centre, 2009) whereas, for Australia, the. 27.

(45) decrease in edentulous adults was from 14.4% to 6.4% in 2006 over a period of 17 years. al. ay. a. (GD, AJ, & KF, 2004) (Marino, Calache, & Whelan, 2014).. M. Figure 2.5: Complete Edentulism. 2.5.6.3 Periodontal Diseases. of. (http://www.dentalnews.com). ty. Chronic periodontitis is a worldwide oral health problem, affecting people of all. si. ages with high prevalence reported among the older population (WHO, 2007). The. ve r. global prevalence of chronic periodontitis is 30-35% among the general adult population with 10-15% of the adult population having a Community Periodontal Index. ni. score of 4 (the most severe score or sign of periodontal disease) (Petersen, Bourgeois,. U. Ogawa, Estupinan-Day, & Ndiaye, 2005).. According to epidemiological surveys conducted in the United States, United. Kingdom, Japan, Korea, India and Australia, around 50-70% of the older population suffer from chronic periodontitis (Petersen & Ogawa, 2012) whereas, according to the National Oral Health Survey in Adults (NOHSA) conducted among Malaysian adults in 2010, the prevalence of chronic periodontitis at 48.5% among the general adult population (Oral Health Division, 2010). Among these adults, 4.1% reported gingivitis,. 28.

(46) 41.4% had calculus, 30.3% had shallow periodontal pockets, and 18.2% had deep periodontal pockets. The mean number of sextants with periodontal disease was 4.48. It was also reported that 94% of dentate adults needed oral hygiene instructions (TN1), 90% required oral hygiene scaling and prophylaxis and 18.2% required complex treatment (Oral Health Division, 2010).. 2.5.6.4. Oral Mucosal Lesions and Oral Cancer. a. Oral cancer, which includes lip, oral cavity, and pharynx cancer, is of prime concern. ay. for individuals aged 65 years and older as they are reported to be 7 times more likely to. al. be diagnosed with oral cancer than persons under 65 years of age (Ries et al., 2000).. M. The prevalence of oral cancer is estimated to increase at an alarming rate according to World Health Organisation estimates, from 10 million new cases globally in 2000, to 15. of. million in 2020 (Mignogna, Fedele, & Russo, 2004). Tobacco use and other risk habits like betel quid chewing and excessive alcohol consumption are all risk factors for. ty. development of oral cancer. Amongst the Malaysian population prevalence of smoking. ve r. si. is high (21.5%) with 46.4% of males being smokers (Oral Health Division, 2010).. Literature has time and again demonstrated the negative impact on oral health of. HIV infection (Poul Erik Petersen et al., 2005) (Cueto et al., 2013). It is estimated that. ni. 40–50% of people who are HIV-positive have oral disease caused by fungal, bacterial,. U. or viral infections that mostly occur early during the disease. Pseudo-membranous oral candidiasis, oral hairy leukoplakia, HIV gingivitis and periodontitis, Kaposi’s sarcoma and non-Hodgkin lymphoma and dry mouth as a result of decreased salivary flow rate are some of the oral lesions strongly associated with HIV infection (Jainkittivong, Aneksuk,. &. Langlais,. 2002). (Jin,. Lamster,. Greenspan,. Pitts,. Scully,. &. Warnakulasuriya, 2016) (Zakaria et al., 2017). 29.

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